Wiki Profee and H & P

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Anna Weaver

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Question concerning OP reports for professional fees. We have always only had the OP report to code from before. Now we have access to the Medical record which includes the anesthesia, H & P etc. Is it okay to code from these as well on the professional side or is this only used for the facility side? I've coded both (facility and professional) and I know facility can code from any part of the chart that is signed off by the physician. Professional side was at a disadvantage in that respect, but with the advent of EMR/EHR can we also use this info? Any help appreciated and if you have resources I would like those as well.
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I only code from the OP report because I code surgeries. Our E&M coder uses the hospital H&P for coding. If you have access to the notes, why would you not use them. However, if you're not the anesthesiologist why would you code anesthesia. Even with EMR/EHR you only code that for which you are responsible.
 
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